“It is encouraging to see CMS fully embrace next generation technologies within traditional healthcare,” says Thomas D. Schwieterman, M.D., vice president of clinical affairs and CMO for Midmark, characterizing Medicare’s expansion of remote physiologic monitoring in the 2021 Physician Fee Schedule. “I feel it has the potential to advance care delivery.”
In the new fee schedule, which became effective Jan. 1, CMS clarified its payment policies related to remote physiologic monitoring (RPM), and made permanent two modifications that were established in response to the COVID-19 public health emergency. Among other provisions, CMS:
- Clarified that after the COVID-19 public health emergency, there must be an established patient-physician relationship for RPM services to be furnished.
- Clarified that the medical device supplied to a patient as part of RPM services must be a medical device as defined by the Federal Food, Drug, and Cosmetic Act; that the device must be reliable and valid; and that the data be electronically (i.e., automatically) collected and transmitted rather than self-reported.
- Clarified that only physicians and non-physician providers who are eligible to furnish evaluation and management (E/M) services may bill RPM services.
Full endorsement
“What is significant, in my mind, is the fact that, with these breakthrough policies, CMS has fully endorsed visits and care that are not face-to-face,” says Schwieterman. “Since the original charter in 1965, the requirement that billable services largely occur at designated points of care has been a staple of how reimbursement is governed at CMS.
“No longer can we simply look at established venues like hospitals, surgery centers, extended care, ambulatory care, and urgent care. The home is now ‘in play,’ and companies that participate in chronic disease care, and acute care for that matter, will need to have effective answers, if not solutions, that incorporate distributed care ‘everywhere.’”
Schwieterman credits COVID-19 with breaking the logjam that has slowed acceptance of remote physiologic monitoring. Prior to the public health emergency, even though the technology and the patients were ready, providers were skeptical of its medical value and just as skeptical of their ability to get reimbursed for offering the service. Meanwhile, payers were spooked by the potential for heavy abuse of the privilege. “The COVID-19 pilot lowered the fear level on the part of all three stakeholders,” he says.
But the need for technology-enabled care – care that is more continuous, asynchronous and virtual – arose long before COVID-19. “It arose mainly because of the rapid acceleration of value-based care and the growing awareness that patients achieve better outcomes at lower cost when their care management is more rigorous and continuous.”
Schwieterman feels that much of the causation of chronic disease, and similarly the poor outcomes for those with chronic disease, stem from poor decision-making by patients and an inability to change unhealthy lifestyles and habits. Remote patient management can directly address both.
What’s more, clinical standards are increasingly calling for at-home physiologic measures. “Diabetes has a very long track record of home monitoring with low-cost glucose meters. The technology is getting better every year, with new platforms that not only record the sugar levels, but also offer insights and behavior modification to improve diabetic control.”
“Recently, the American Heart Association, along with the American Medical Association, American College of Cardiology and others, have advocated for home blood pressure as a validation path to diagnose and manage hypertension. The list of chronic diseases that use at-home sensors is destined to grow as payers target reimbursement payments (incentives) to reward care teams that reduce cost and lower patient morbidity.”
‘Virtual care is here to stay’
Remote monitoring has great potential for helping patients effectively manage their chronic conditions, allowing physicians to intervene earlier to improve patient outcomes and decrease healthcare costs, says Steven Waldren, M.D., vice president and chief medical informatics officer for the American Academy of Family Physicians. What’s more, the fact that the 2021 fee schedule opened the door for remote monitoring for patients with acute conditions – not simply chronic care management – is another good sign. “CMS is saying, ‘We think virtual care is here to stay, and there are multiple ways to apply it.’”
CMS’ insistence that an established patient-physician relationship be in place for RPM services will help limit fraud and abuse and help ensure that any remote monitoring is coordinated with the patient’s usual source of care, says Waldren. “As we see further expansion of virtual services after the public health emergency, it is in the best interest of patients that those services are coordinated and continuous with their longitudinal care. Also it is much more likely that downstream costs – the costs of the virtual service – will be higher if that virtual service is not part of a patient’s comprehensive primary care.”
The final rule’s stipulation that remote monitoring data be electronically – that is, automatically – collected and
transmitted rather than self-reported could present some challenges, he continues. “A concern is the lack of standards and conventions in place for RPM devices to electronically transmit. It is likely that at least each manufacturer may have its own custom approach to transmitting the data. This is likely to dramatically increase the administrative burden on practices and make data integration into the EHR difficult.
“Nor will manufacturers consider how the data streams from these devices should be analyzed to provide physicians and practices with actionable dashboards. It could be a logistical nightmare for a practice if they are getting raw data streaming into the practice, as practice staff will likely have to log into multiple portals to access the streams. What is needed is smart software, which can provide appropriate alerting and creation of patient- and population-appropriate dashboards.”
No substitute
These new physician payment rules will open doors to innovation, says Schwieterman. But they will not replace traditional care. “When behavior modification is a central theme to improving outcomes, a relationship with a trusted clinician is a logical predecessor. Remote banking did not replace your bank or your banker; it just made banking more convenient. The established doctor-patient relationship remains a central theme and will be for many years to come. CMS understands this; hence, the rule set we see here.
“CMS needs to be credited with their remarkably swift action on clarifying the rules, especially during the chaos and financial crisis brought on by a global pandemic. But, like any governmental action, the road is certain to be bumpy and curvy. Undoubtedly there will be new twists and turns for years to come as this new means of care gets fully integrated into the lexicon. Providers can expect a few false starts, some unexpected surprises – both good and bad – and frequent revisions.”